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The emergence of the coronavirus disease (COVID-19) pandemic in March 2020 created unprecedented challenges in the provision of scheduled ambulatory cancer care. As a result, there has been a renewed focus on video-based telehealth consultations as a means to continue ambulatory care. The aim of this study is to analyze the change in video visit volume at the University of California, San Francisco (UCSF) Comprehensive Cancer Center in response to COVID-19 and compare patient demographics and appointment data from January 1, 2020, and in the 11 weeks after the transition to video visits. Patient demographics and appointment data (dates, visit types, and departments) were extracted from the electronic health record reporting database. Video visits were performed using a HIPAA (Health Insurance Portability and Accountability Act)-compliant video conferencing platform with a pre-existing workflow. In 17 departments and divisions at the UCSF Cancer Center, 2284 video visits were performed in the 11 weeks before COVID-19 changes were implemented (mean 208, SD 75 per week) and 12,946 video visits were performed in the 11-week post-COVID-19 period (mean 1177, SD 120 per week). The proportion of video visits increased from 7%-18% to 54%-72%, between the pre- and post-COVID-19 periods without any disparity based on race/ethnicity, primary language, or payor. In a remarkably brief period of time, we rapidly scaled the utilization of telehealth in response to COVID-19 and maintained access to complex oncologic care at a time of social distancing.

Outpatient rehabilitation plays a vital role in providing post-discharge care for stroke survivors' optimum recovery. Geographic variability in access to post-stroke rehabilitation care in rural areas is poorly understood. This study used Medicare claims from 2016 to 2019 to estimate incidence of stroke discharges home and compared rehabilitation utilization rates after discharge from acute hospitalization in the state of Texas. We also examined spatial accessibility to post-discharge outpatient rehabilitation centers between rural and urban areas. We supplemented claims results with a survey to better understand locations where outpatient rehabilitation clinics provided services to stroke patients. After discharge from the hospital, patients from rural counties neighboring urban counties had lower adjusted predicted probabilities of using outpatient clinic services compared to urban areas. Patients with primary diagnosis codes of stroke sequelae: adjusted relative rate of 0.84 (CI: 0.76,0.93) with an adjusted rate difference of -0.05 (CI: -0.08, -0.02), cerebral infarction: adjusted relative rate of 0.82 (CI: 0.72,0.91) with adjusted rate difference of -0.04 (CI: -0.06,-0.02), hemorrhagic patients: adjusted relative rate of 0.81 (CI: 0.71,0.91) with an adjusted rate difference of -0.04 (CI: -0.06,-0.01). We did not find discernable differences between rural and urban areas for home health utilization or the combination of outpatient clinic services with home health as a single category. Estimates from a floating-catchment spatial accessibility model scaled from 0 (worst access) to 1 (best access) showed that, compared to urban counties, indices in rural not adjacent to urban counties were -0.16 (CI: -0.23, -0.08) lower and -0.14 (CI: -0.20, -0.08) lower in rural areas in counties adjacent to urban counties. Compared to urban areas, rural areas have lower spatial access to and utilization of outpatient clinic services in the state of Texas.

Background An international panel achieved consensus on 9 need-based and 2 time-based major referral criteria to identify patients appropriate for outpatient palliative care referral. To better understand the operational characteristics of these criteria, we examined the proportion and timing of patients who met these referral criteria at our Supportive Care Clinic. Methods We retrieved data on consecutive patients with advanced cancer who were referred to our Supportive Care Clinic between January 1, 2016, and February 18, 2016. We examined the proportion of patients who met each major criteria and its timing. Results Among 200 patients (mean age 60, 53% female), the median overall survival from outpatient palliative care referral was 14 (95% confidence interval 9.2, 17.5) months. A majority ( n  = 170, 85%) of patients met at least 1 major criteria; specifically, 28%, 30%, 20%, and 8% met 1, 2, 3, and ≥ 4 criteria, respectively. The most commonly met need-based criteria were severe physical symptoms ( n  = 140, 70%), emotional symptoms ( n  = 36, 18%), decision-making needs ( n  = 26, 13%), and brain/leptomeningeal metastases ( n  = 25, 13%). For time-based criteria, 54 (27%) were referred within 3 months of diagnosis of advanced cancer and 63 (32%) after progression from ≥ 2 lines of palliative systemic therapy. The median duration from patient first meeting any criterion to palliative care referral was 2.4 (interquartile range 0.1, 8.6) months. Conclusions Patients were referred early to our palliative care clinic and a vast majority (85%) of them met at least one major criteria. Standardized referral based on these criteria may facilitate even earlier referral.

Background Studies show that hospital deaths bring significant health care costs, and the involvement of specialized palliative care can help to reduce these costs. The aim of this retrospective registry-based study was to evaluate end-of-life hospital costs in patients dying in a university hospital oncology ward, with or without specialized palliative outpatient clinic contact at any timepoint. Methods The study population consists of all patients who died in the Kuopio University Hospital oncology ward in the years 2012–2018 ( n  = 457). Hospital costs in the last 30 days of life and data on treatment decisions and background factors were gathered. Costs for patients with and without palliative care contact were compared. Effects of various variables on the costs were analyzed using gamma regression model. Results Both the last 14 days’ and 30 days’ hospital costs before death were significantly lower among those 65 patients [14.2%] who had had a specialist palliative care contact. This was seen in inpatient day costs, microbiology, radiation therapy, laboratory, drug, radiology, and total costs. In a multivariate analysis including age, gender, year of death, time from diagnosis to death, and cancer type, the costs for 30 days prior to death were 33% lower in those patients who had had palliative care contact. Conclusions Our results provide first indications that a contact to specialist palliative care in an outpatient clinic may reduce end-of-life hospital care costs in hospital-deceased cancer patients.

ObjectiveTo compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.DesignA retrospective cohort study.SettingThis study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays.ParticipantsInclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma.Main outcome measuresThe primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients.ResultsWe included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)).ConclusionsThe incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Outpatient clinic access for patients diagnosed with non-emergent ocular conditions has been shown to decrease patient load in the Emergency Department (ED)/Urgent Care and improve patient satisfaction with care. We sought to quantify referral completion rates and ED/Urgent Care visit durations at a pediatric tertiary care center and analyze how demographic factors may influence these quality indicators. We discuss an overarching strategy to improve access to subspecialty care through a same-day access program. We retrospectively reviewed ED/Urgent Care patient encounters from 2019 to 2024. Patients diagnosed with conjunctivitis, vision loss, corneal abrasion, or iritis referred for follow-up care were included in this report. Visit duration in the ED/Urgent Care, referral completion rates, and patient demographics were analyzed. Seven hundred six patient encounters met the initial inclusion criteria. The average visit duration in the ED/Urgent Care per month was 3.36 hours (median, 3.45; IQR, 2.84-3.81), the average proportion of incomplete referrals per month was 21.9% (median, 20%; IQR, 10.6%-30%), and average proportion of ED/Urgent Care visits over 4 hours per month was 33.1% (median, 33.3%; IQR, 21.3%-43.5%). Demographic subgroup analysis (n = 411) revealed a relationship between age, insurance status, zip code, and race with completed referral rates and visit duration in the ED/Urgent Care. Our results indicate long visit durations in the ED/Urgent Care and a large proportion of incomplete referrals for patients with non-emergent ocular issues. A same-day access program could streamline access to subspecialty care by moving patients directly to the ophthalmology department from the ED/Urgent Care.

ABSTRACTAshodaya Samithi, an organization run by and for female, male, and transgender sex workers in Mysore, India, has worked since 2004 to prevent sexually transmitted infection (STI)/human immunodeficiency virus (HIV) transmission and improve HIV cascade outcomes. We reviewed published and programmatic data, including measures of coverage, uptake, utilization and retention, and relate STI/HIV outcomes to evolving phases of community mobilization. Early interventions designed “for” sex workers mapped areas of sex work and reached half the sex workers in Mysore with condoms and STI services. By late 2005, when Ashodaya Samithi registered as a community-based organization, interventions were implemented “with” sex workers as active partners. Microplanning was introduced to enable peer educators to better organize and monitor their outreach work to reach full coverage. By 2008, programs were run “by” sex workers, with active community decision making. Program data show complete coverage of community outreach and greater than 90% clinic attendance for quarterly checkups by 2010. Reported condom use with last occasional client increased from 65% to 90%. Surveys documented halving of HIV and syphilis prevalence between 2004 and 2009, while gonorrhoea declined by 80%. Between 2005 and 2013, clinic checkups tripled, whereas the number of STIs requiring treatment declined by 99%. New HIV infections also declined, and Ashodaya achieved strong cascade outcomes for HIV testing, antiretroviral treatment linkage, and retention. Program performance dropped markedly during several periods of interrupted funding, then rebounded when restored. Ashodaya appear to have achieved rapid STI/HIV control with community-led approaches including microplanning. Available data support near elimination of curable STIs and optimal cascade outcomes.

Background Many clinics in Southern Africa have long waiting times. The implementation of point-of-care (POC) tests to accelerate diagnosis and improve clinical management in resource-limited settings may improve or worsen clinic flow and waiting times. The objective of this study was to describe clinic flow with special emphasis on the impact of POC testing at a large urban public healthcare clinic in Durban, South Africa. Methods We used time and motion methods to directly observe patients and practitioners. We created patient flow maps and recorded individual patient waiting and consultation times for patients seeking STI, TB, or HIV care. We conducted semi-structured interviews with 20 clinic staff to ascertain staff opinions on clinic flow and POC test implementation. Results Among 121 observed patients, the total number of queues ranged from 4 to 7 and total visit times ranged from 0:14 (hours:minutes) to 7:38. Patients waited a mean of 2:05 for standard-of-care STI management, and approximately 4:56 for STI POC diagnostic testing. Stable HIV patients who collected antiretroviral therapy refills waited a mean of 2:42 in the standard queue and 2:26 in the fast-track queue. A rapid TB test on a small sample of patients with the Xpert MTB/RIF assay and treatment initiation took a mean of 6:56, and 40% of patients presenting with TB-related symptoms were asked to return for an additional clinic visit to obtain test results. For all groups, the mean clinical assessment time with a nurse or physician was 7 to 9 min, which accounted for 2 to 6% of total visit time. Staff identified poor clinic flow and personnel shortages as areas of concern that may pose challenges to expanding POC tests in the current clinic environment. Conclusions This busy urban clinic had multiple patient queues, long clinical visits, and short clinical encounters. Although POC testing ensured patients received a diagnosis sooner, it more than doubled the time STI patients spent at the clinic and did not result in same-day diagnosis for all patients screened for TB. Further research on implementing POC testing efficiently into care pathways is required to make these promising assays a success.

Background Osteoporosis is a highly prevalent disease identified by Dual Energy X-ray Absorptiometry (DEXA) that can be performed in an ambulatory (out-patient) or hospitalized population. We evaluated the use of baseline in-hospital DEXA screening to identify osteoporosis in ambulatory care and hospitalized patients; we also assessed specific risk factors for osteoporosis among these populations. Methods We included a baseline initial DEXA from 6406 consecutive patients at our tertiary referral University Hospital. Results Osteoporosis was diagnosed in 22.3% of the study population. In univariate analysis, osteoporosis risk factors were age, fracture history and low BMI (for all 3 sites), but also corticotherapy (lumbar spine and femoral neck) and male (lumbar spine). In multivariate analysis, age, fracture history, low BMI, and male increased osteoporosis risk. In-hospital screening yielded a higher percentage of osteoporosis positive scans than ambulatory care screening (31.8% vs 18.5%, p  < 0.001). In-hospital screening targeted an older and more predominantly male population with a higher fracture history. Z-scores revealed that this difference was not only due to an older age of the population and mainly concerned cortical bone. Conclusions In-hospital osteoporosis screening revealed more osteoporosis than screening in ambulatory practice and could be an additional tool to improve the identification and management of osteoporosis. In addition to typical risk factors, we identified male gender as associated with osteoporosis detection in our cohort.

Many teaching hospitals in the US segregate patients by insurance status, with resident clinics primarily composed of publicly insured or uninsured patients and faculty practices seeing privately insured patients. The prevalence of this model in obstetrics and gynecology residencies is unknown. To examine the prevalence of payer-based segregation in obstetrics and gynecology residency ambulatory care sites nationally and to compare residents' and program directors' perceptions of differences in quality of care between payer-segregated and integrated sites. This national survey study included all 6060 obstetrics and gynecology residents and 293 obstetrics and gynecology residency program directors in the US as of January 2023. The proportion of program directors reporting payer segregation was calculated to characterize the national prevalence of this model in obstetrics and gynecology. Perceived differences in care quality were compared between residents and program directors at payer-segregated sites. The primary measure was prevalence of payer-based segregation in obstetrics and gynecology residency programs in the US as reported by residency program directors. The secondary measure was resident and program director perceptions of care quality in these ambulatory care settings. Before study initiation, the study hypothesis was that residents and program directors at ambulatory sites with payer-based segregation would report more disparity in perceived health care quality between resident and faculty practices compared with those from integrated sites. A total of 251 residency program directors (response rate, 85.7%) and 3471 residents (response rate, 57.3%) were included in the study. Resident respondent demographics reflected demographics of obstetrics and gynecology residents nationally in terms of racial and ethnic distribution (6 [0.2%] American Indian or Alaska Native; 425 [13.0%] Asian; 239 [7.3%] Black or African American; 290 [8.9%] Hispanic, Latinx, or Spanish; 7 [0.2%] Native Hawaiian or Other Pacific Islander; 2052 [62.7%] non-Hispanic White; 49 [1.5%] multiracial; 56 [1.7%] other [any race not listed]; and 137 [4.2%] preferred not to say) and geographic distribution (regional prevalence of payer-based segregation: 36 of 53 [67.9%] in the Northeast, 35 of 44 [79.5%] in the Midwest, 43 of 67 [64.2%] in the South, and 13 of 22 [59.1%] in the West), with 2837 respondents (86.9%) identifying as female. Among program directors, 127 (68.3%) reported payer-based segregation in ambulatory care. University programs were more likely to report payer-based segregation compared with community, hybrid, and military programs (63 of 85 [74.1%] vs 31 of 46 [67.4%], 32 of 51 [62.7%], and 0, respectively; P = .04). Residents at payer-segregated programs were less likely than their counterparts at integrated programs to report equal or higher care quality from residents compared with faculty (1662 [68.7%] vs 692 [81.6%] at segregated and integrated programs, respectively; P < .001). In this survey study of residents and residency program directors, payer-based segregation was prevalent in obstetrics and gynecology residency programs, particularly at university programs. These findings reveal an opportunity for structural reform to promote more equitable care in residency training programs.